This is part 3 of a 3-part series: EMR 101.

Along with Step 4, Step 5 starts to open the door into EMR 201: Getting Really Good.

If EMR 101 is about surviving the day, EMR 201 is about getting efficient, which enables you to think widely and deeply about patient care, as well as proactively.

Step 5a: Abstract

Abstracting refers to distilling old chart or patient record info directly into your EMR. It differs from scanning those other records, in the same way that data is different from information – one is raw potential, the other is immediately useful.

• A scanned chart, or hospital discharge summary, is just a snapshot, an image in your medical record reference files. It can be accessed and read, and key info extracted, but until someone actively accesses, reads, and extracts that information, it stays “hidden” in that stored picture.
• An abstracted record, on the other hand, has those key elements already extracted and transferred into your EMR where it can be quickly accessed.

More important than speed, that abstracted information can spring into action in your electronic medical record.

“Will no one rid me of this meddlesome transcription?”

So the date of  a colonoscopy report can trigger an alert when the patient’s next one is due. The date of a flu shot can trigger a reminder to give them another one this winter.

Abstracting jump starts a patient’s chart; without it, you’re missing critical information you need to treat patients on the spot. The key is to streamline that initial process.

Preferably, without you being the one doing it all, especially during the first patient visit when you should be focusing on other matters.

Step 5b: Delegate

Ideally, the electronic chart should be ready for you from the very moment you “open” it during your first patient contact.

Yeah, right.

A physician often ends up being the one inputing the “critical info set”:

• meds
• allergies
• dates of certain past tests
• diagnostic codes corresponding to diagnoses for the chronic conditions list

This results in the most accurate carryover, but at a high cost. Abstraction at this point is little more than transcribing — words from paper column A, entered into data field B. If you’re doing this regularly, congratulations on being one of the most highly paid and frustrated typists on earth.

Get good at entering the diagnosis codes, especially, and remember: this is temporary.

Delegation rears its screaming head, here — “Will no one rid me of this meddlesome transcription?” — but it actually starts long before. If your data source is legible, like from a typed hospital discharge note or a clear-clear chart summary sheet, you’re in luck. It’s possible to assign office staff (or hire personnel) to do the transfer, as closely as the day before the patient visit.

If your data is illegible, like your own handwritten notes (or where the critical data is scattered throughout), you’ve got to suck it up, plain and simple.

Get good at entering the diagnosis codes, especially, and remember: this is temporary. As the patient visits increase, the visits themselves build the necessary context for future judgments.

As long as you’re accepting new patients, the abstracting and delegating will never entirely disappear. To keep it manageable — and guard against imported data that you haven’t approved — consider the following physician/staff workflow:

1. Never allow records to be scanned without you signing off on them. The last thing you want is a damning piece of buried data that you will be responsible for, that you never saw, except at deposition.
2. Keep an inbox for documents from elsewhere, and using the previously mentioned batch processing method, work through it steadily at set times of the day.
3. Have a highlighter, or better yet, sticky pad labels (the kind that mark forms where you have to sign?), and mark the info bits you want your staff to enter into the chart, such as
   • entire EKG’s
   • dates of colonoscopies, mammograms, Pap smears, vaccines
   • any other “stick pin” items you must track or update over time
4. Pass the documents to staff in an outbox, to enter just the choice highlighted bits, then off to the general scan pile.

This way, you are not being bogged down with abstracting, your staff isn’t having to wade through and interpret an entire note for the few bits of interest, and nothing gets scanned without being cleared, first.

The next to last step to work on, on your march towards EMR mastery:

Step 4: The 80/20 Rule

Also known as “The Pareto Principle,” the 80/20 Rule is extraordinarily useful. It’s a principle of economics and management, and is most often cited today by entrepreneurs (like Tim Ferris) needing to keep vast amounts of data and responsibilities manageable. Sound familiar?

At the EMR 101 level, the 80/20 Rule goes like this:

• the vast majority of your daily patient encounters occur around a handful of clinical diagnoses

which translates into

• the vast majority of your daily documentation can be done with a handful of templates or pages.

This was alluded to in the last post, under Step 2: Get Familiar With TWO Workflows, Tops. You can go far with this one; long after you’ve graduated to speedier, more specific templates, you’ll still be able to fall back to your “old faithful” workflows whenever confronted with a condition laying outside of what your EMR was designed to handle.

But this principle extends way beyond this:

• 80% of your headaches come from 20% of your patients
• 80% of your office income comes from 20% of your health plans
• 80% of your inbound calls are about the same 20% of daily tasks (e.g. refill requests and lab reviews)
• 80% of your going home late comes from 20% of your documenting habits (e.g. doing crib notes, then going back later to reconstruct the full notes)
• and so on

Once you start seeing these trends, you can start to prioritize where to direct your attention most efficiently. In medicine, of course, you’re trying to encompass 100% as your goal; the 80/20 Rule is NOT about letting 20% of your work go undone, or missing the critical diagnosis 20% of the time!

But if you’re swimming in a morass of seemingly undifferentiated tasks, this rule can identify what to fix first to give yourself the most breathing room. Make 2 or 3 changes that lift the “crush” of your workload off of your back, and you will be much less worn down.

And “much less burnt out” means “less likely to miss critical things.”

Take That Step, You Can Do It

Think about it: take a bit of time now — when you’re floundering, I know — to regain yourself heaps of time from now on.

Push back from your desk and find a handful of problems to fix — pick 2 to start with. I’ve had great success with the following, which ultimately enabled me to end my workdays about an hour earlier than before:

1. batch processing lab reviews or med refills for 15 minutes at noon, and 15 minutes at the end of the day (instead of sprinkled throughout the day — barring any urgent values, of course)
2. finishing notes as you go, and getting rid of the “crib notes/reassemble later” habit

See how much time and energy you get back with just those changes. Then look again, find some more “big bang for your buck” issues, and go at it again.

Reclaim your day, one swipe at a time.

Next time: EMR 101, Part 3 – The Final Chapter

I’ve seen it in a variety of practices, my own being no exception.

Free texting to document a patient encounter.

You’ve got your clickers, the orientation spiel goes, and ya got your typers.

Me, I’m a typer, but the system allows you to document any way you like. To each his own, and I love the look of my own text!

So, when your IT folks suggest that you align yourself with the clicker column, so to speak, you might find yourself getting a mite…testy. Vocally belligerent, even — it’s a free country, and I’ll free text, doggone it.

What follows are some thoughts about why you might want to reconsider. Reeeally reconsider…

“Join Or Die”

America’s first political cartoonist, Benjamin Franklin, penned the following image, encouraging the colonies to pull together, during the French and Indian War:

A bit ominous, granted, but you get the drift. United we stand, divided we fall. And if you’re curious, the officially sanctioned “EMR cause” to join these days is discrete data entry — button clicking.

Free texting is that squirrelly separatist inclination that weakens everyone, in the face of hostile forces. Which makes sense from a strategic perspective: everyone proudly doing their own thing with a disdain for documenting consistency, can’t be good from a unity standpoint.

But in this case, the enemy isn’t France and its agents on the 18th century frontier — and if you want to text freely, the enemy isn’t your EMR vendor, either.

It’d be easier for them to make an EMR into a big, free-text machine (they’re called “word processors”), and infinitely harder to make it into the interlocking databases that true EMR’s are. Keeping track of button clicks and cross referencing list choices must be planned out in advance, with tons of user input and testing. If it’d get the job done, EMR vendors would be ecstatic at doing away with all that data juggling, and letting doctors type, cut, copy, and paste on blank screens.

Collectively, the “enemy” of free texting your entire note is any and all forces that make discrete data tracking a necessity. I’ll come back to that in a bit, but for now, remember:

Lesson #1: There’s a wolf at the door, and much as we’d like to blame the establishment, it’s NOT the EMR vendor.

So Big Vendor’s Our Friend, Eh?

You’d better believe it.

Keep in mind that any business, especially a moderately big one, will prefer to keep its internal processes simple, and its customers happy.

In EMR Vendorland, the current trend is towards button clicks and list choices, despite the fact that

1. doing so involves much more programming complexity, and
2. loads of physicians, especially from small groups or solo provider offices, want free texting

Better yet, this same group loves text macros — small programs that can run in parallel with EMR software, enabling sentences or paragraphs of a doctor’s own text to be recalled and inserted with a few keystrokes.

So are EMR vendors purposefully peeing into the wind? Doubtful, or they won’t be around for long.

Lesson #2: The EMR vendor wants to keep you a happy, faithful customer; there’s a reason for the apparent paradox in not recommending free text, everywhere for ever and ever, amen.

So What’s More Important Than Market Share?

And quite a slice of the marketing pie it is.

According to the National Ambulatory Medical Care Survey in 2003, 38.5% of physician practices are solo practices, with 73.1% of all patient visits occurring to doctors offices with 4 or fewer providers — and more than half of those visits are to solo practitioners’ offices.

And pardon me for saying so, but there’s a certain correlation between small/solo practices and wanting to document freely. You can’t make it in a small private practice without singing “My Way” in the shower all through med school.

Put 2 and 2 together, and you’ve got a lot doctors and patient visits potentially leaning towards the free texting movement. As in, “2 out of 5″ practices, and “7 out of 10 patient visits.”

If EMR vendors aren’t aware of this math, and are deliberately pissing off folk who may prefer documenting their own way, that’s a pretty suicidal business strategy.

UNLESS…there’s something more detrimental to the vendors’ future than pissy small or solo group customers.

Lesson #3: If the healthcare system itself tanks, we’re all going down.

“I’ll Kill You Later”

I’ve alluded to better and brighter minds than mine in a previous post. Apparently, the new Health & Human Services Secretary, Tom Daschle, and President-elect Obama are among them: EMR’s are figuring universally in any major plan to fix the American Health Care system.

My understanding of this is evolving, but in a nutshell, whether fatally broken or just really badly in need of repair, you need accountability to have a hope in heck of fixing the system. Meaning, track what is going where, how much it costs, what your outcomes are, and how long it takes you to get there. Get a baseline, tweak, reassess, and repeat.

THAT’s the basic, iterative mechanism that is coming (and It Cometh On Like Gangbusters):

• What’s your specialty’s average “score” at treating Condition X?
• How does your particular practice measure up?
• What are your competitors’ scores?
• How do they compare on cost?
• How do they compare on convenience?
• Why should patients come to you if your overall measures are lower?

You see where this is heading?

Re-rank the following, in order of overall significance:

• Survival of the entire healthcare system
• Survival of your practice within it
• Your insistence that “ctrl-U” spits forth your personal Urinary Tract Infection protocol on the progress note

Lesson #4: Time to get our heads out of the sand — we can argue documenting convenience later, but we will need stats and numbers to fight with real soon. For the survival of our practices, as well as the system, itself.

Youcandoitthehardway…

Or you. Can. Do. It. The. Easy. Way.

Believe me, you’ll want to do it the easy way, because “it” is going to mean combing through the data of your practice, your region, maybe even your specialty, not just for one medical outcome, but many, and not just once, but periodically, on demand, as your practice and patient demographic changes.

Again, this is the Iceman that is coming. THIS is the wolf at the door: assessing, improving, and justifying your practice’s data. It won’t matter whether it’s for your medical director, your IPA, an insurance carrier, or a government agency — data mining is as inexorable as an avalanche, and as such, you don’t argue with it, you just deal with it.

Free text strings are gobbledygook to computers. The most beautifully worded, stylistically perfect text paragraph is just one long ream of alphanumeric characters to a computer. Meaningless, so far as data mining goes, like a string of Attic Greek characters with no spaces in between.

That’s nonsense, you say, I can run a search on my text heavy records, by specifying a search string! I always use “A1c” when referring to my diabetics’ glycohemoglobin, and I always put it in field 271 on the progress note! Don’t tell me my EMR can’t accommodate my particular free texting when it comes to running reports on my diabetics!

That’s great, really it is.

What about your partner? Or your other local colleagues, or your group as a whole? Are all of them using “A1c,” or or some of them using “HbA1c,” or “a1C?” Maybe some of them put the value in field 271, but others don’t enter it at all, it’s entered automatically into the lab module via a lab interface, on page 2, field 37(b).

Your report generating strategy takes a geometric leap upwards in complexity, the minute you step out of your own practice. Why can’t different EMR’s consistently talk to one another? Sheesh, why can’t individual doctors document in the same way?

It’s Like The Jim Croce Song

Listen to a copy, if you can find one; it’s a cutie:

You don’t tug on Superman’s cape.

You don’t spit…into the wind.

You don’t pull…the mask off the old Lone Ranger,

And you don’t mess around with Jim.

Lord knows, solo and small group providers fight the good fight, every day. And not all such doctors resist “documenting digitally,” as I put it, i.e. with discrete data clicks.

But as anyone in the industry knows, it’s a recurrent phenomenon, and a recurrent refrain:

I want to document in the free text blank spaces, I want to copy and paste previous just-so notes, and I want to do so everywhere — history, exam, plan, all at once, preferably.

That impulse is understandable; it’s behind some vendors’ efforts to create “do it once, remember it forever” options for saving and re-using favorite pages.

But too often, there’s another impulse on the heels of that one: I could care less about data mining, or defending myself in case of a chart audit, or making it easy to compare my “numbers” with my peers’. Less, in other words, about any concern but my own documenting speed and ease.

Newsflash: if you count yourself among this group, the days when speed and ease were your biggest worry are OVER.

There’s a reason for going along with clicks, and it’s spelled D-A-T-A. With it, you and your fellows can go toe-to-toe with The Wolf, The Iceman, Jim, and his successor, Slim.

Just Click and Save, boys. Just Click and Save.

Switching gears a bit: I was honored to be a co-presenter this year, on the final day of User Group.

My colleague and I were curious about who would show up on the last conference day, especially after the late night festivities the night prior (Huey Lewis And The News, and KC And The Sunshine Band).

Thankfully, folks did show for the 9 AM session, and didn’t leave in droves, either.

Good Cop, Bad Cop

Our talk focused on the importance of cooperation at the upper levels of the management team, if you want a successful EMR roll-out. As alluded to in The Leadership Secrets Of Joseph Stalin, inspired by Dr. Cephus Allin, this means melding “physician champions” and “practice administrators” into a cohesive, irresistible team.

The administrator-realist role…is a full-time occupation, like herding toddlers.

No matter what size organization you have, from 2 to 200+, if you want a smooth adoption of an EMR system, you need someone who can play hardball, and someone who can encourage: bad cop/good cop, Stalin/Mother Teresa, administrator/physician champion.

This is more an observation of human nature, and what has transpired in many implementations I’ve observed:

• Some physicians and staff will be all for the transition
• Some will be undecided
• Some will be either hostile or passive aggressively against it

The administrator-realist wears the project manager hat, and cracks the whip to get that last group squarely behind — or out of the way of — the EMR adoption train. That role is absolutely necessary, whether referring to the office manager in a small group office, or the COO of an MSO. It is also a full-time occupation, like herding toddlers.

But guess what? We physicians have an individualist streak a mile wide, and instinctively resent heavy handed tactics, even while we privately admit the need for them.

Enter The Physician Champeen

It’s not a new idea, designating a physician in the organization to champion the cause of the EMR. What follows is our take on why having one isn’t just a good idea, it’s critical to the success of your EMR endeavor:

1) Physicians Are Social Creatures, Individualism To The Contrary

You’ve seen this time and time again: when a company rep explains an EMR to a doctor, he gets a skeptical response, but when an EMR-using physician explains the same points to the doctor, it’s a revelation! It’s miraculous! Where do I sign?

This is even true if the EMR physician gives a less-than-perfect presentation. The company rep is often an IT person, and knows the system better than the doctor.

Why is the EMR physician’s presentation so much better received than the rep’s?

Because before they became individualist practitioners, doctors had already been socialized into a professional social structure: the medical profession, itself. They may have entered med school as God’s gift to the world, but they left it as part of the medical establishment, stripped down and built back up in a health sciences boot camp.

An organization gets only so many catastrophes before the doctors lose faith…Head off even one of them, and the champion has earned his keep for the year.

And what do you do, once you’ve been socialized? You listen real good to thems what have gone before you. Snarling surgical residents quake in their clogs when the senior attending stares at them.

An EMR-using physician, who has survived a system adoption process with all its struggles, has immediate street cred with his or her colleagues. Doctors will listen to a member of the fellowship, because that’s how professionally socialized members have been trained to act.

2. The Physician Champion Stays In And Acts Out

An organization should only need to have its head handed to it on a platter once…before it realizes the value of a physician champion.

The conventional idea of a champion sallying forth with The Flag Of EMR Truth overlooks another, key role: advising internally, amongst the IT and EMR administrative staff.

The external role is fairly clear:

• You demonstrate the software, preferably live in your busy office
• You educate patients, doctors, and organizations about it
• You help new users “get up to speed”
  • in person
  • by writing teaching material
  • by creating AV tutorials, like Camtasia instructional videos

In essence, you show and expound upon the product, with the incomparable credibility of a colleague who’s been there, done that, and still is.

But the internal advisory role is arguable even more critical, especially from an organizational standpoint:

• Testing designs for viability, before release
• QA checks for glitches that only a doctor would appreciate
• Suggesting new features that would make doctors’ lives easier

Going back to the drawing board is a royal pain. An organization should only need to have its head handed to it on a platter once, by a group of irate docs, before it realizes the value of a physician champion who can save endless hours of software rewrites.

God forbid your docs utter that ultimate phrase of damnation:

Take it offline and give us back the last version until you fix it and get it right.

An organization gets only so many catastrophes before the doctors lose faith, and wander off in all directions into the dark. Head off even one of them, and the champion has earned his keep for the year, in user good will and saved IT staff headaches.

In this neck of the woods, there’s a goodly number of folks who’ve taken the plunge, and adopted an EMR.

Cold sweats, galore.

With that in mind, here are some thoughts from a fellow user who’s been there and done that, to remind you that you can, too!

Old Charts Are Old Hat

Remember that scanning and abstracting is a temporary fix.

This is pretty key, since it’s easy to get bent out of shape over the old paper chart contents. Many new EMR users have a Linus-like fixation on their paper charts as security blankets, or the scanned and hopefully abstracted version thereof. Totally natural, since the early go-live days feel like flying without a net — but it’s ultimately a short-lived, transitional state.

Within one to two years (which can seem an eternity away when you start), you will no longer be digging even digitally into the “old chart,” since your EMR by that point will be the old chart. And finding info in your EMR should be infinitely easier and quicker than flipping through scanned images of paper documents.

That’s why it’s important at the beginning, to have your scanned info be categorized for relatively quick access, either by filing them in obvious categories like LABS, IMAGING, EKG, and CONSULT NOTES, or abstracting whenever possible (summarizing paper chart data in brief entries into the EMR itself). Scanned images take time to load and display, and often can’t be flipped through rapidly. When you have to dig for info, you want to know approximately where to go looking, instead of “somewhere in that 67 page document file.”

Just remember – you won’t be relying too heavily on those scanned documents for long.

Getting Quick And Smooth, Baby

Next, there’s getting comfortable — and fast — with the system.

Most of this is sheer repetition, like the flying hands of ultrasound techs as they twiddle the trackball and tweak the sliders and knobs with one hand, direct the sono wand with the other, while looking at neither. Practice, practice, practice.

It’s important to avoid tripping yourself up, and one of the biggest hurdles is the “I must click every button and fill in every blank line” syndrome. Unless you were the original designer of the templates, doing so is very unlikely to resemble your old workflow, and you will lose valuable time filling out what feel like financial aid forms for every patient encounter.

Your biggest ally is your technical support. Good support will be always available to assist you, by analyzing your prior workflow and helping you transition to a new, EMR inclusive workflow. They can tell you — and reassure you — about what needs to be filled out, and what can be left alone. Often, they can show you much speedier ways of filling out standard history or exam items, than you painstakingly typing out every finding.

Remember — these systems were designed to be used in real-world patient care environments. The EMR vendors wouldn’t exist as viable businesses, if they required users to multiply their workloads by a factor of 5 at every turn. You have the option of documenting each pertinent positive and negative, one at a time, in as much detail as you desire — the system has to give you that drill-down capacity. But just as you’ve developed efficient ways of being speedy yet detailed over the years, so have the EMR developers.

It is an entirely attainable goal, documenting a patient encounter accurately and completely, so that the entire note and all actions related to it are done before you see your next patient. Ask your support folks to show you how, and with practice, the speed and ease will come.

“Is It Safe?”

Finally, there are Good Habits.

Good and Safe, from an EMR perspective, doesn’t just mean speedy and accurate, it also means medico-legally sound. That means taking advantage of the extraordinary power that an EMR gives you, that relying on your own fallible protoplasm alone cannot.

Workflow analysis from your tech support will again be key, here. Your EMR has the capacity to remember every data element, and to remind you when things were done, not done, or when they are due. It won’t forget something because it felt tired one day, or because it got distracted.

You can basically take advantage of your tireless digital servant in 2 ways: what I call automation with patient encounters, and automation by time frame.

Automation by encounter is you paying attention when the system tells you to do something during a patient encounter — whether that be during a patient visit, a phone call, or prescription refill request. An “encounter” occurs whenever YOU or an office staffer lay hands on the chart.

Most EMR’s can alert you when certain pre-defined criteria have been met. These are either preset by the manufacturer (e.g. your 50 y.o. female patient is now due for her mammogram), or defined by you with your tech support (I want the system to jog my mammogram memory with my 35 y.o. female patients). A Good Habit to get into is routinely paying attention to and acting upon these alerts, regardless of the reason for the encounter.

• Is a patient seeing you for a sprained ankle, but overdue for their mammogram? No harm at all in printing up the mammo order and gently reminding them as they limp to the check-out.
• Is the pharmacy calling for a refill on the patient’s nasal spray, and the system telling you he’s overdue for his annual physical? Why not remind the patient to schedule one, and document that you did so?

The law looks upon every contact you have with the chart as an opportunity to act on deficiencies that are documented there. Fair or not, you may as well take advantage of the EMR’s ability to remind you of the biggies, and act on them whenever the chance presents itself. Look at your system’s version of an Alerts page with every encounter, and don’t ignore little red flags when they pop up.

Automation by time frame requires a bit more work — the idea is to systematize a method of acting on those patients who rarely if ever contact your office. And who would therefore be missed if you relied on “capturing” them during an encounter that may never materialize.

Since EMR’s don’t ever forget, you should be able to periodically generate reports of patients who fit certain search criteria. Getting your system to spit out a list of all your female patients between 18 and 65 who haven’t had a Pap smear in the past 12 months should be easy. Or a list of all your patients who missed their follow-up appointments this last month.

Whatever criteria matter to you, you can have the system track patients down using them. Decide upon a limited, implementable set of sweep criteria (start with 3 to 5, not 38), and strain your practice periodically.

You’ll pick up more tidbits as you go along, especially if you participate in a local users group meeting or regular EMR Committee to finesse the system, and your own use of it. Start slow, don’t hesitate to ask for pointers, and get some good habits started at the outset.

And you’ll do fine.

In this new age of modern, enlightened EMR-hood, there is no way around it:

You will have to get cozy with your IT support staff.

Really cozy. On better terms with them than your spouse, cozy.

Unless you want to be spending at least as much time working with your hardware, software, and systems integration issues as you do with patient care — and even then, not fully taming the tech side.

I’ve been up to my armpits in EMR related work, advising an MSO that supports a local implementation in Southern California. New upgrades and conversions, retraining folks and developing teaching materials, testing the new features with the MSO programmers, filing down the rough edges to fit…

Finding new rough edges, and filing those down.

Pulling all nighters.

It’s a full time job, and I’m only consulting half time!

And I’m an interface and end-user testing guy; I’m not even writing or re-writing the actual software code.

Not In the Military, But…

Think about what you, as a provider of medical services, do daily:

You have a supply chain a mile long, relying on phone staff, back office assistants, pharmaceutical suppliers, and colleagues in other offices or hospitals.

Communication with your patient is critical — and often less clear than both of you would like.

And technology — whether electronic record, appointment reminders, or email, blog, and text messaging — can either help you or hurt you, as is true of any tool. But it can’t substitute for the basic human skills of attentiveness, empathy, and careful consideration through the lens of experience.

I don’t have a hidden wish to be in uniform, but I believe we really are the civilian version of the military’s “pointy tip of the spear.” When it comes to health care, what we do is about as mission critical as things get.

No argument so far, I trust.

Pobody’s Nerfect

There’s always been what’s been termed “the fog of war,” and likely always will be. No matter how many good people and good intentions and conscientious preparation you have on your side, there’s no such thing as a guaranteed, painless path to victory.

“Real boats rock,” as Frank Herbert said. No day starts off so gloriously that it can’t go to heck in a handbasket in an instant.

Poop happens.

This isn’t a theory; it’s a historical observation of the entropy of the universe. While it may not be as bad as my senior surgical resident said (”See that parking lot out there? Every one of those cars is full of people just waiting to bag you”), there are imperfections in any system. Chaos Theory, in fact, tells us that imperfections aren’t oversights or the consequences of poor parental upbringing, they are by definition going to be present in any sufficiently complex system.

Real boats don’t rock because the shipwright didn’t design the keel properly. They rock because that’s what the ocean does.

And of course, in the grand system of EMR, IT staff, office support, family, and colleagues, one of the biggest parts that can “rock,” will be us.

How many of us can even control our selves enough to traipse smoothly through life’s dandelion patches?

The best we can hope for is a setup that corrals our imperfections, that will encourage us to do our duties better, and that will do so forgivingly, instead of fighting against us.

So What Can YOU Do?

There are imperfections, and there are eye-crossing logistical nightmares in the making.

Having your IT support “distant” from your peculiar implementation falls under the latter category of SNAFU.

Out of the area tech support works, if you have an ultra standardized setup — the exact same hardware, software, and interfaces in your office that the tech support person in Bangalore has during your phone call.

But in today’s EMR world, that just ain’t so. Customizations unique to your office typically occur within weeks or months, and as I alluded to in a prior post, the network partners change locally within just a few miles of any implementation (different pharmacies, different hospitals, different laws, different interfaces).

Distance does not make the heart grow fonder, in the EMR support world.

In my opinion, you keep your friends close, your enemies closer, and your EMR IT support closest of all. Get them to marry into the family, if possible. You will need them much more often than the proverbial plummer, auto mechanic, and lawyer.

Next, reconsider slitting your own throat:

In my experience, the best clinicians and workers among us are often somewhat demanding and periodically rigid – you have to be, to get things done in a sea of entropy. You know people like this, may even be one of them: they tell it like it is, say bald, unvarnished things, and are generally a little unpleasant to go visit.

IT people love folks like that. Really, they do.

There’s a difference between the clinicians that don’t read the instructions and don’t care to, and the clinicians who have an honest beef with the system because it isn’t helping them win the war. Professionally, IT staff always admire and respect the latter.

Those clinicians are trying to close the distance between what wins battles here, and what doesn’t out of the box from the manufacturer over there. And closing the distance is what makes everyone smile, in IT support.

BUT, there’s too much of a good thing sometimes: piss and vinegar can make smiles tight, real quick. And if you could care less about irritating people while you loftily maintain your personal integrity, think back to the military analogy, or even your med school days:

• Do the lieutenants piss off their sergeants?
• Do the sergeants piss off their supply contacts?
• Do the med students piss off the floor nurses?

Kind of universally vital, those “support” folks.

Get thee hence from the prima dona mindset; your digital future rests squarely on the shoulders of a village of IT support staff, shucking and jiving at the speed of light. You will never voluntarily want to be far from them, and they wouldn’t have jobs without you.

Make nice.

Another nifty tip from the NextGen Users Group Meeting.

Dr. Cephus Allin spoke in some detail about it, as did at least one other presenter; I’m pretty sure this is passing into the NextGen cannon of “Successful Practices Do THIS — So Should You.”

It sounds so simple, but I can attest to its profound effects on reclaimed time — and best of all, it works regardless of your EMR platform. And with a sensible use of technology, it will work regardless of your office size.

The concept is “Having everyone in the office practice to the top of their licensure.” It basically means this: docs should do doc level tasks, MAs should do MA level tasks, and clerical/phone staff should do clerical and phone intake tasks.

Or more bluntly:

• Do you really want the $100/hr physician spending 5 minutes per encounter rooming a patient (an MA level task)?

• Should the MA spend 3 minutes per chart entering lab values (a clerical level – or better yet, automatable – task)?

Many tasks that physicians now assume they need to do can be handled by staff empowered to do so, within the upper but acceptable limits of what they’re supposed to do.

Make Your MA Your Faithful Scribe

HPIs and Systems Reviews are usually taken by the physician, but often can be done just as well — and much more consistently — by the MA.

Common HPIs can be filled out by the MA as he or she rooms the patient by clicking through a template, then reviewed in seconds by the physician upon entering the room. Same for a Review of Systems during an annual physical. These two tasks alone can free up minutes per visit – and even 3 minutes per visit over 20 patients a day means an extra hour of free time.

Concerned about the defensibility of that “all normal” ROS button, or the “past medical history reviewed – unchanged” button? Not if your customary practice is to have your MA read, verbatim, each line or question, and click the appropriate box.

This isn’t about shoving the scut onto your support staff – that would be suicidal. Ultimately, it’s about improving the workflow for everybody in the office, by having them sensibly do what they’re best trained for, and not burning gears doing other folks’ busywork while their own duties get put off.

If you’re a physician and you’re updating the meds lists, or an MA and you’re abstracting paper chart info, your office needs to step back and rethink your duties.

Trim The Fat And Snap To In 3 Steps

The basic mechanism goes like this:

1) ASSUME from the beginning that each team member in the office has a finite set of doable, key tasks, that if performed well, will have the EMR enabled office running smoothly. This is actually a reasonably safe assumption to make, for a perversely inverted reason: you’re screwed if this isn’t true, so you might as well start off on a positive note.

2) EXAMINE those tasks, and group them into categories appropriate to the particular team member: physician level tasks to the docs (needing higher level decision making, training, or “the boss” factor), clinical assisting and communicating tasks to the MAs, and clerical or phone duties to the front office or phone staff. Those meds lists should be updated by the front office or the MA, not the MD.

3) AUTOMATE whenever possible to reduce each team member’s tasks to manageable levels — something that an EMR enabled office can excel at.

Not sure where your MA is going to magically find the extra time to do data entry of all those incoming lab values? Push for that interface with the lab, so the results are automatically entered electronically into the chart, for your review and approval – MA properly out of the loop, saving her hours per day.

Have access to a secure email communication portal with your patients? Run, don’t walk, to get it incorporated into your EMR. Especially if it allows boilerplate text macros for commonly given instructions or responses to frequent questions, it will save tons of time that your staff now spends on simple patient notifications.

• Example: time yourself typing the instruction to adopt a low fat diet and regular exercise in response to that most common of primary care lab abnormalities, the elevated cholesterol result.

• Then time your MA re-transcribing that, putting it in an envelope, stamping it, and putting it in the outgoing mail pile, or worse, calling a patient, finally getting the patient on the phone, having to chat about it, then documenting it.

• THEN compare that total time to 2 mouse clicks — one on the “exercise and diet” instruction button, the other on the SEND EMAIL TO PATIENT button. Multiply that by the dozens of times daily a typical PCP gets abnormal cholesterol values, and you begin to see how supposedly itty bitty efficiencies can reclaim hours of lost time.

Me Scan? I Thought You Scanned?

What about abstracting and scanning old charts — who decides what’s important, and who feeds the sheets through the scanner? This is a whole topic in and of itself, but the same rules apply:

While docs are arguably the best arbiters of key chart info, it’s not an efficient use of their time to have them abstract or scan (see $100/hr, above). Everyone needs to have a pitch-in whenever needed attitude, yes, but do the math: if you fit in just ONE extra patient per day, that’s 23 extra patients in an average month, or an extra day of income. That’s enough to hire an extra scanning staffer who can even do the abstracting, if you give clear and simple directions on pulling info from a patient chart.

And with the increased efficiencies throughout the office, you should be able to squeeze in more than one extra patient, in addition to the cumulative savings of all those other process improvements (better billing and coding, less time wasted, etc).

Share The Wealth

The examples are almost limitless where practice life can be made better all the way around — that most desirable win-win-win situation for everyone in the office including the patient.

When the EMR alerts you when patient is overdue for something like a mammogram or a diabetes lab, any of the support staff should be able to generate the order and contact the patient to do it. Empowering them to automatically do so de-pressurizes the MD’s and frees them up for higher level tasks. And EMR automation can make the generating and contacting processes quicker than ever for the MA or front office staff.

Just remember to combine the proper delegation of “top licensure” with workflow changes that will make that delegation possible. Delegate down, but pull staff up, so to speak.

Okay, so maybe that’s gutting inefficiency in TWO moves.